How do you 'prove' that your patient needs physical therapy and is benefiting from your care.
Many physical therapists think that the patients verbal statements "I feel better!" placed in the written chart is sufficient to justify services to Medicare patients.
Many therapists use a simple outcome measure to show progress and demonstrate need.
Is one simple outcomes measure and patient "subjective" statements sufficient to exceed the $1,840 therapy cap?
Probably not.
Centers for Medicare and Medicaid (CMS) Transmittal 88 states the following:
"It is encouraged but not required that narratives that specifically justify the medical necessity of services be included in order to support approval when those services are reviewed."(p.23)A narrative is a statement that says "Here is why I am putting the '-KX' modifier on my charges - here is why I think my patient qualifies for Medicare Part B benefits over the therapy cap."
A separate justification statement may be included either as a separate document or within the other documents if the provider/supplier wishes to assure the contractor understands their reasoning for services that are more extensive than is typical for the condition treated. A separate statement is not required if the record justifies treatment without further explanation. (p.24)"If the record justifies...
That is a big IF...
This Justification Statement is the one my facility uses to PROVE our patient deserves their rightful Medicare benefits.
It also protects me from unfair fines or repayments if I get audited.
Disclaimer: I am a physical therapist in private practice - not a Medicare auditor. You should make your own decision as to the veracity of my statements and the extent to which my recommendations fit with your own compliance program.
I do not give individual compliance advice.
Note in the Justification Statement how various levels of clinical evidence support and reinforce each other:
- outcomes measures
- performance measures
- impairment measures
- written patient statements
"Documentation should establish through objective measurements that the patient is making progress toward goals. Note that regression and plateaus can happen during treatment. It is recommended that the reasons for lack of progress be noted and the justification for continued treatment be documented if treatment continues after regression or plateaus." (p.26)Your patients deserve the therapy they need.
Some facilities automatically discontinue physical therapy when allowed charges hit $1,840 - regardless of whether patient goals are met.
Is that fair?
